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' APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICTN 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described. This application is made in c fiance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin ealth District. „3 e Jab Address City Lot Size � PM ddress Phone Qwner's Name , Contractor I Address License No. Phone PE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER i DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES - DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL E OTHER WPITS/SUMPS 4 INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPE ATIONS ❑ Industrial ❑ Open Bottom ❑LManteca Dia. of Wel! El tion Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Type asing Specifications f 1 Public Cl Other 171 epth of Grout Seal Type of Grout 1 1 Irrigation - —__Approx.?Depth l ln Surface Seal Installed by - r Repair Work Done LJType of Pu H.P. State Work Done- Well Destruction ❑ iameter Sealing Material [top 501 ^ Depth j Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION 13 DESTRUCTION (No septic system permitted if public sewer is available within 200 feet,) Installation will serve: Residence Commercial— Other V 1 Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ I Method of Disposal 'Distance to nearest: Well Foundation Prop6rty.Line LEACHING LINE ❑ No. & Length of lines Total length/size , FILTER BED ❑ Distance to nearest: Well Foundation Property Line ' f SEEPAGE PITS 11 Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin Local Health Di§trict. Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not employ any person in such manner as to become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- bon laws of California." The applicant must call for all equired i pections. Complete drawing on reverse side. Signed Title: Date: r FOR DEPARTMENT USE ONLY �^ Application Accepted by Date Area �1 Pit or Grout Inspection y Date Final In action by ro - Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave:, P.O. Box 2009, Stk., CA 95201 i FEE gMOUNT DUE' AMOUNT REMITTED RECEIVED BY DATE PERMIT IVO. INFO ' +.EH 13-241REV.)iH5] EH 14.28